Restoring dignity: Mental Health Act Review

The Independent Review of the Mental Health Act 1983 has set out recommendations for government on how the act, and associated practice, needs to change. We explore what the review says and, more importantly, what it means for primary care

The 1983 Mental Health Act is the basis for all mental health treatment and care in the UK. Nearing 40 years of age, in 2017 prime minister Theresa May announced an independent review of the act to address the concerns of healthcare professionals and service users, including worries about human rights and dignity. Fundamentally, the review aimed to assess how relevant the act is for the healthcare system and wider society today – and tomorrow.

The review engaged patients, professionals, third sector organisations and other key stakeholders to understand how the act is interpreted and how it is translated into patient care. The final report was published in December 2018 and was welcomed by the healthcare system, stakeholders and others, including Dr Paul Lelliott, deputy chief inspector of hospitals (lead for mental health) at the CQC, who said, “The Independent Mental Health Act Review has been a much-needed opportunity to consider how to improve the care and treatment received by the thousands of people affected by the act each year.”

In a written response the healthcare regulator, ‘strongly supports’ the review’s calls for more rights, better treatment and greater patient involvement in care planning.

Reducing complexity

It’s acknowledged within the review that the 1983 Mental Health Act grants healthcare professionals significant powers, but that its complexity can be confusing to those who use it – and those who are subject to it. To simplify matters, the review proposes that any new act should be simplified and be enshrined around some core concepts, including:

• Choice and autonomy – ensuring service users’ views and choices are respected.
• Least restriction – ensuring the act’s powers are used in the least restrictive way.
• Therapeutic benefit – ensuring patients are supported to get better, so they can be discharged from the act.
• The person as an individual – ensuring patients are viewed and treated as rounded individuals.

The report runs to over 300 pages and is a challenging read. The prevailing view is that the act needs to be altered to reflect modern England and Wales – countries that have changed significantly since the early 80s.

Independent charity MIND, who were involved in the review itself conclude that the review seeks to give greater legal weight to the wishes and preferences of patients. In future, clinicians will be expected to have much stronger and transparent justifications for using their compulsory powers.

The recommendations include:

• Introducing advance choice documents so that people can set out their wishes about future care and treatment, which would have more weight than they do in the current system.
• Advocates for all mental health inpatients (whether voluntary or detained) without having to ask for one.
• Advocates who are skilled in responding to people’s cultural needs.
• A statutory care and treatment plan to include people’s wishes.
• Earlier access to a second opinion, and a right to appeal against treatments.
• More scope for tribunals to respond to people’s concerns about their care.
• Choice of which friend or family member has a role in decisions about sectioning and care, by making the current ‘nearest relative’ role a ‘nominated person’ who you can choose yourself.
• A complete end to the use of police cells when initially detained, and an end to the use of police vehicles for taking people to hospital.
• A systematic approach to improving how mental health services respond to their local population’s ethnic and cultural backgrounds.

The core of the report is around increasing patient choice and engagement within their own care. It reflects the more diverse society in which we live, encouraging all healthcare providers to deliver services that are inclusive.

The review signals a move away from inpatient care, describing detention as a last-resort for patients. Instead, the review proposes greater community-based care. This echoes the feelings among patients who prefer independence, but will naturally demand greater co-ordination of care – something the review acknowledges the system hasn’t always managed appropriately. The new statutory ‘Care and Treatment Plan’ is the cornerstone of the act, the review states, with the focus on discharge planning beginning as soon as the patient is admitted.

The NHS Long Term Plan announced an investment in community services for those with long-term mental health problems, but there are concerns as to whether this will be enough. If not, primary care could be called upon to pick up the slack.

You can read the full Modernising the Mental Health Act report here.

You can read the CQC’s response to the publication of the review here.

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